PANRE Flashcards
(156 cards)
1
Q
screening and monitoring for AAA
A
One time screening for men 65-75 who smoked
Size matters
3-4.4 - yearly us
4.5-5 - 6 months, refer to vasc surgery
5-5.4 - 3 months
>5.5 or > 0.5 cm expansion in 6 months = surgery
2
Q
Treatment for aortic dissection
A
Tx: ascending = surgery; descending = medical mgmt (BB), surgery if needed
3
Q
glycoprotein IIb/IIIA inhibitors
A
During PCI
abciximab, tirofiban, eptifibatide
6-24 hrs
4
Q
Myocarditis
A
Patho: inflammation with global enlargement
SSX: SOB, palpitations, fever, weak pulses, S3 gallp
Dx: trops, EKG-sinus tach, ESR/CRP, biopsy (gold)
tx - supportive
5
Q
Pericarditis
A
Patho: inflammation of pericardium
Uremia, viral, TB, RA, SLE, drugs, radiation
S/Sx: dyspnea, friction rub, pericardial effusion, CP better leaning forward, pleuritic pain with inspiration
Dx: EKG, ?bx
Tx: NSAIDs, rest, colchicine
Pearls:
Dressler syndrome = pericarditis 1-6 wks after MI, surgery, injury
Tamponade
6
Q
Abdominal aortic aneurysm
A
Patho: dilation of wall of aorta
S/Sx: pulsatile mass, abd pain, hypotension
Dx: ultrasound, CTA
Tx: lower bp, surgery
Pearls:
One time screening for men 65-75 who smoked
Size matters
3-4.4 - yearly us
4.5-5 - 6 months, refer to vasc surgery
5-5.4 - 3 months
>5.5 or > 0.5 cm expansion in 6 months = surgery
7
Q
Aortic dissection
A
Patho: separation of tunica intima and blood between layers
S/Sx: severe “tearing” pain, hypotension or hypertension, tachy
Dx: CTA (MRA is gold standard); CXR = widened mediastinum
Tx: ascending = surgery; descending = medical mgmt (BB), surgery if needed
8
Q
NSTEMI
A
Patho: plaque disruption, plt aggregation, clot formation
S/Sx: diaphoresis, cp, dizzy, hypotension
Dx: EKG, cath (delayed 24-48 hrs), elevated troponin
Tx: stent, bypass
Meds = BB, NTG, Statin, aspirin, Plavix, heparin, ACEI
Pearls: MONA
No benefit from tpa
9
Q
STEMI
A
Patho: same as NSTEMI, complete occlusion
S/Sx: CP, diaphoresis, hypotension
Dx: EKG, immediate cath, elevated troponin
Tx: stent/bypass
Meds = BB, NTG, Statin, aspirin, Plavix, heparin, ACEI
MONA
Tpa if no cath
Pearls:
10
Q
Unstable angina
A
Patho:
Unstable - new stenosis, not occlusion
S/Sx: ch pain
Dx: EKG, troponin, stress test, cath if indicated
Tx: nitro, BB, aspirin, plavix, CCB, ACEI, statin
Pearls:
11
Q
Stable angina
A
Patho:
Stable - stenosis, not occlusion
S/Sx: ch pain - predictable with stable angina
Dx: EKG, troponin, stress test, cath if indicated
Tx: nitro, BB, aspirin, plavix, CCB, ACEI, statin
Pearls: Printzmetal - spasms of arteries, no stenosis; avoid BB; give nitrates
12
Q
arterial embolism
A
Patho: clot from heart or plaque; afib or mitral stenosis
S/Sx: pain, pallor, pulseless, paresthesia, paralysis, cold (polar)
Dx: CTA, echo
Tx: embolectomy, anticoagulant; amputation
Pearls:
Lower > upper
13
Q
atrial septal defect
A
Atrial septal defect:
Patho: failure of heart wall to close
S/Sx:
Sob, palpitations, DOE
systolic , upper left sternal border, early/mid rumble, fixed S2 split inspiration and expiration
Dx:
CXR - enlarged pulm artery, cardiomegaly, R enlargement
EKG - RBBB, RAD, RVH
Echo - left-to-right shunt
Tx: diuretics, ACEI, digoxin; surgical closure if needed
Pearls:
Complications - PHtn, HF
14
Q
Ventricular septal defect
A
Patho: defect in septum
S/Sx:
Young kid
Fatigue
Harsh holosystolic, left lower sternal border with no radiation
Dx: Echo
Tx: watchful waiting, surgery
Pearls:
Complications - PHtn, HF
15
Q
Tetralogy of Fallot
A
Tetralogy of Fallot:
Patho:
Pulmonary stenosis
Overriding aorta
VSD
RVH
S/Sx:
Tet spells, failure to thrive, squatting
Harsh cresc/decresc systolic, left upper sternal border
Dx: CXR - boot-shaped heart; Echo
Tx: Surgery
Pearls:
16
Q
Coarctation of the aorta
A
Patho: stenosis
S/Sx:
In arch - different pulses/BP in arms
After arch - different pulses / BP arms vs legs
Systolic murmur in left scapular region
Dx: CTA; CXR= “figure of 3” and rib notching; Echo; MRA
Tx: surgery repair or angioplasty
Pearls:
HTN from low renal blood flow
50% have bicuspid aorta
Risk of cerebral berry aneurysm, aortic rupture/dissection, CVA (untreated = death before 50 on average)
Neonates - give prostaglandin E1 to keep ductus open
17
Q
Patent ductus arteriosus
A
Patho: failure of DA to close after birth
S/Sx:
Continuous machinery murmur left upper sternal; bounding pulse with widened pulse pressure
Failure to thrive in newborns
Tachypnea, tachycardia
Dx: Echo
Tx: NSAIDS (inhibitor of prostaglandin) - indomethacin; surgery if needed
Pearls:
18
Q
Thoracic aortic aneurysm
A
Patho: dilation of thoracic aorta - ascending, descending, arch
Risks: HTN, DLP, smoking, connective tissue disorders, infection, vasculititis
S/Sx: chest pain, cough, dysphagia, hoarseness, SVC syndrome, dissection
Dx: CXR - widened mediastinum, echo (TEE for ascending), CTA
>5.5 cm (4.5 if Marfan)
Tx: lower BP (BB), monitoring, surgery
Pearls:
Complications - aortic valve regurg
Test for syphilis
19
Q
Varicose veins
A
Patho: failure of venous valves with engorgement; lower extremities
Risks: HTN, obesity, standing, women
S/Sx:
pain, sense of fullness
varicosities
Dx: visual exam; doppler ultrasound (reflux)
Tx:
Compression
Elevation
Sclerotherapy
Surgery
ablation
Pearls:
20
Q
Venous insufficiency
A
Patho: venous hypertension from obstruction, limited movement
Risks: obesity, HTN, DVT, smoking, lax ligaments (flat feet, hernias)
S/Sx:
Restless legs; nocturnal cramping; Ulcers
Medial malleolus ulcer; hemosiderin staining; edema
Dx: Doppler ultrasound
Tx: Leg elevation; exercise; Compression, wound care
Pearls:
21
Q
Peripheral artery disease
A
Patho: stenosis of arteries
Risks: smoking, DM, DLP, HTN, male, obesity
S/Sx:
pain/claudication; neuropathy; weakness; pain at rest/lying down
Pale; hairless; reduced pulses; muscle atrophy; dry gangrene ulcers; cool
Dx: CTA; ABI < 0.9; lipid panel
Tx: angioplasty, bypass; stop smoking; cilostazol or aspirin/plavix; statin; ACEI; exercise
Pearls:
Stop BB if PAD severe
Avoid vasoconstrictors
22
Q
Phlebitis
A
Patho: inflammation of superficial vessels +/- thrombus
S/Sx:
Pain, edema
cord-like
Dx: Doppler US
Tx: Rest, elevation, compression, NSAIDS; anticoagulation if needed
Pearls:
23
Q
Giant cell arteritis
A
Patho: inflammation of medium vessels; autoimmune/viral; monocyte activation and cytokine production with inflammation and tissue destruction; extracranial branches of carotid - temporal, occipital, ophthalmic, post ciliary
S/Sx:
Claudication of jaw; vision loss; HA; tender scalp
Cord-like temporal artery
Dx: Doppler US; temp artery biopsy; ESR/CRP
Tx: anticoagulation; high dose predisone for 1-2 yrs (IV if vision loss)
Pearls:
Overlap with PMR
Rule of 50 - age > 50; ESR > 50; prednisone > 50
24
Q
Atrial fibrillation
A
Patho: multiple signals in atria; irregular conduction thru AV node
Risks: alcohol
S/Sx:
Palpitations; sob; syncope;
Irregular pulse
Dx: EKG; Echo
Tx: rate control; cardioversion; anticoagulation
Pearls:
CHADS2VASC and HAS-BLED
25
Atrial flutter
Patho: re-entrant circuit in RA
Risks: COPD, HF, ASD, CAD
S/Sx:
Palpitations; SOB
Dx: EKG
Tx: rate control; cardioversion; ablation; anticoagulation
Pearls:
26
AV block
Patho: delayed conduction thru AV node
1st, 2nd type 1 and 2, 3rd
Risks: ischemic heart disease; idiopathic fibrosis; drugs
S/Sx: dizziness, syncope/near syncope, fatigue, SOB
Dx: EKG
Tx:
2nd and 3rd need pacer; r/o ischemic disease
Pearls:
27
Bundle branch block
Patho: delay in signal in AV branch or fascicle
Risks: ischemic heart disease; RBBB - lung disease, PE
S/Sx:
Fatigue; palpitations; SOB
Dx: EKG; echo
Tx: usually none, unless new LBBB - ischemia w/u; ppm if symptomatic
Pearls:
28
PSVT
Patho: re-entrant circuit, usually with AV node
Types: PSVT, WPW, AVNRT, AT, MAT
Risks: WPW
S/Sx:
Palpitations; syncope/near syncope; dizziness; SOB
tachycardia
Dx: EKG; monitor
Tx: vagal maneuvers, adenosine, synchronized cardioversion; rate control; ablation if WPW
Pearls:
29
Premature beats
Patho: irritability
Risks: drugs, ischemia, fibrosis, stress, caffeine, COPD, electrolyte issues
S/Sx:
Heart jumping, palpitations
Dx: EKG, monitor; echo
Tx: usually none; CCB/BB; ablation; antiarrhythmic with PJC
Pearls:
Bigeminy and trigeminy - regular pattern
30
Sinus node dysfunction
Patho: dysfunction of impulse generation in SA node
Types: sinus brady, sinus pause, sinus arrest, brady-tachy (50%), SA exit block
Cause: idiopathic fibrosis; inflammatory disorders; infiltrative disorders
S/Sx:
Dizziness, flushing, weakness, fatigue, syncope/near syncope, DOE, angina
Dx: EKG, monitor
Tx: PPM for quality of life
Pearls:
31
Torsades de pointes
Patho: multifocal ventricular signals, alternating
Risks: electrolyte imbalance (K, Mg low);
prolonged QT (ABCDE causes)
anti-Arrhythmics
antiBiotics
antiCychotics
antiDepressants
antiEmetics
S/Sx:
Cp, sob, doe, unconscious, syncope
Dx: EKG, monitor
Tx: IV Mg; unsynch cardioversion
Pearls:
32
Ventricular fibrillation
Patho: irregular firing from multiple loci in ventricles
Risks: ischemia
S/Sx:
unconscious
Dx: EKG
Tx: unsynch cardioversion; epinephrine, amiodarone
Pearls:
33
Ventricular tachycardia
Patho: reentrant firing of ventricular loci; 3 or more beats
Risks: ischemia, drugs, dilated cardiomyopathy
S/Sx:
Syncope, palpitations, cp, sob, doe, dizziness
Dx: EKG, monitor
Tx: synch cardioversion; amiodarone (lidocaine, procainamide); ICD
Pearls:
34
Bradycardia
Patho: sinus node dysfunction, medications
S/Sx:
Dizziness, fatigue, syncope/near syncope
Dx: EKG
Tx: atropine, transcutaneous pacing
Pearls:
35
DVT
Patho: clot in deep veins
Risks: immobility; hypercoag; trauma; OCP
S/Sx:
Pain; edema
Homan +;
Dx: Doppler US; d-dimer
Tx: anticoagulation
Pearls:
36
Cardiogenic shock
Patho: low EF
Causes: MI, wall rupture, tamponade, air embolus, PTX, PE, valve dysfunction, myocarditis, trauma
S/Sx: confused, obtunded, lethargic
Weak pulses, tachy; cool extremities; hypotension; KVD
Dx: EKG, Echo; pulm cap wedge pressure
Tx: O2, pressors, fluids vs diuretics, surgery
Pearls:
37
Dilated cardiomyopathy
Patho: 95% of cardiomyopathies
Risks: viral, emotional, alcohol, HTN, postpartum, chemo, endocrine, myocarditis, infections (Trypanosoma, Coxsackie B, HIV, toxo), beriberi, thyrotoxicosis
S/Sx:
Fatigue, sob, doe, cough, loss of appetite
Crackles, edema, S3, JVD
Dx: Echo - 4 chamber dilation, MVR, TVR
Tx: BB, ACEI, diuretics, SGLT2i; ICD; LVAD; transplant
Pearls:
38
Hypertrophic cardiomyopathy
Patho: enlargement of the septum; usually genetic
S/Sx:
DOE, dizziness with exertion, syncope
Murmur - systolic, left sternal border; DECREASES with squatting or handgrip, INCREASES with valsalva or standing; S4 gallop; JVD
Dx: Echo
Tx: ablation, BB/CCB; ICD
Pearls:
Avoid diuretics, nitrates, ACEI/ARB, low volume; avoid digoxin
Sudden cardiac death in young athletes
39
Restrictive cardiomyopathy
Patho: infiltrative disease, scar tissue, thick pericardium
Risks: amyloidosis, sarcoidosis, hemochromatosis, radiation, chemo, scleroderma
S/Sx:
Dob, sob, edema
JVD, edema, S4
Dx: Echo
Tx: address cause; cautious diuretics
Pearls:
40
Systolic heart failure
Patho:
left/right - hypertrophy, damage
High output HF - hyperthyroid, severe anemia, beriberi or thiamine deficiency
S/Sx:
Left - pleural effusion, sob, doe, fatigue, edema, PND
S3, crackles, displaced apical
Right - edema, sob
JVD, hepatomegaly (lungs are clear)
Dx: Echo; Right HF = R heart catheterization; BNP
Tx: SGLT2i, ACEI/ARB/ARNI, BB (coreg, metoprolol succinate), diuretic, aldactone; ICD
Right - treat lung disease
Others
Hydralazine + isosorbide dinitrate
Ivabradine (if can’t use BB or maxed out)
Digoxin
vericiguat
Pearls:
NYHA scale
Class 1 - no symptoms with activity, +structural changes on imaging
Class 2 - symptoms with ordinary exertional activity
Class 3 - symptoms with less than ordinary activity
Class 4 - symptoms at rest
Wait 36+ hrs between ACEi/ARB and starting Entresto to reduce angioedema
41
Diastolic heart failure
Patho: usually restrictive
S/Sx:
Edema, fatigue
Edema, hepatomegaly, jvd, S4
Dx: Echo
Tx: ACEI + BB/CCB; NEVER digoxin
Pearls:
42
Primary hypertension
Patho: usually idiopathic;
Risks: HTN, sedentary, poor diet, obesity
S/Sx:
Usually none
Elevated BP
Dx: BP 2 readings, 2 different visits, no cause; eye exam, renal function, EKG
Tx: start with thiazide diuretic, ACEI
Pearls:
Normal - < 120/80
Elevated 120-129/<80 — lifestyle changes, reassess 3-6 m
Stage 1 130-139 or 80-89 – assess 10 yr risk; < 10% as above, >10% add 1 med
Stage 2 >/= 140 or >/= 90 – lifestyle + 2 meds
Crisis >180 or > 120
Goals: <140/90 if age < 60, <150/90 if age > 60
Retinopathy = AV nicking
Meds
ACEI = cough, angioedema; NOT in pregnancy
BB = NOT in asthma; impotence
CCB = edema
Hydralazine = lupus, pericarditis
Pregnancy: labetolol, nifedipine, methyldopa
43
Hypertensive emergency/urgency
Patho:
S/Sx:
HA, vision changes
Elevated BP; +/- organ damage - papilledema, AKI, bilirubin, aortic dissection, pulm edema, MI/angina, AKI, confusion
Dx: BP
Tx:
Urgency - can evaluate outpatient; 2 drug regimen; clonidine
Emergency - reduce BP 10-20% in 1 hour, then 5-15% over next 23 hrs. (no more than 25% total); sodium nitroprusside
Pearls:
If aortic dissection, lower to < 140 immediately
44
Secondary hypertension
Patho:
Primary aldosteronism, CKD, renovascular, OSA, pheochromocytoma; Cushings; congenital adrenal hyperplasia, hyperthyroidism, myxedema; coarctation; alcohol; oral contraceptives
S/Sx:
Depends on disorder
Dx: Depends on suspected disorder; BMP, renal artery doppler, catecholamines, cortisol, 17-progesterone, TSH, imaging
Tx: depends
Pearls:
45
Vasovagal hypotension
Patho: often vasovagal; meds; low cardiac output; stress
S/Sx: dizziness, cold sweat, palpitations, syncope
Dx: EKG; tilt table test
Tx: avoid triggers; BB; ppm
Pearls:
Usually in age < 40
46
Orthostatic hypotension
Patho: autonomic dysregulation; medication; postprandial’ hypovolemia; adrenal insufficiency
S/Sx:
syncope/near syncope; dizziness; confusion; falls
Drop in BP < 20/10 2-5 minutes after change in position
Dx:
Tx: midodrine; remove cause; reduce blood pooling in legs; more salt
Pearls:
Meds - alcohol, alpha blockers, anti-depressants, parkinson drugs, antipsychotics, BB, diuretics, relaxants, analgesics, sedatives, PD4i, vasodilators
47
Pericardial effusion
Patho: fluid accumulation in pericardium
Risks: viral infection, bacterial infection, pericarditis, cardiac injury, autoimmune, cancer, radiation, ESRD, hydralazine
S/Sx:
Sob, tachycardia, better sitting forward, pain with inspiration (radiate to shoulder/back)
Muffled heart sounds, electrical alternans on EKG, pulsus paradoxus
Dx: CXR (water bottle), Echo
Tx: diuretics, pericardiocentesis
Pearls:
48
Cardiac tamponade
Patho: fluid in pericardium constricts RV causing low output
S/Sx:
Sob, fatigue, syncope
Muffled heart sounds, hypotension, JVD (Beck’s triad - distant, distended, decreased); pulsus paradoxus, narrow pulse pressure
Dx: Echo, CXR, EKG - electrical alternans, low QRS
Tx: pericardiocentesis, IV fluids
Pearls:
49
Bacterial endocarditis
Patho: bacterial ball on valve
Risks: IVDU, rheumatic fever, bicuspid aorta, artificial valve, dental work, central line; Men>women
S/Sx:
Fever, malaise
Osler nodes, Roth spots, splinter hemorrhages, Janeway lesions, murmur
Dx: Echo, TEE if needed, blood cultures
Tx: IV abx
Pearls:
Most common: Staph aureus, Strep viridans (most common), HACEK, Enterococcus
HACEK = Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
Duke criteria:
2 major, 1 major + 3 minor, 5 minor
Major:
+ blood cultures x2
+echo
Minor:
Predisposing risk
Fever
Vascular phenomena: pulm infarcts, ICH, janeway lesions, arterial embolus, conjunctival hemorrhage
Immune phenomena: Osler nodes, Roth spots, glomerulonephritis
One positive blood culture
Serologic evidence of infection by typical cause
Abx prophylaxis = 2g amoxicillin
50
Rheumatic heart disease
Patho: infection with Group A Strep (S. pyogenes) - inflammatory reaction due to antistreptolysin Ab
S/Sx:
Arthralgia, chest pain, fatigue, fever,
Dx:
Jones criteria (initial diagnosis of rheumatic fever)
Tx:
10 days pen/amox
Prophylaxis -
5 yrs if no carditis
10 yrs if carditis, no valvular damage
>10 yrs if carditis with damage
Pearls:
Jones criteria
2 major or 1 major/2 minor AND evidence of GAS infection
Major: Jones
J = joints
O = heart - carditis
N = nodules - subcutaneous
E - erythema marginatum (annular, non-pruritic, trunk/limbs)
S = Sydenhams chorea
Minor:
Arthralgia
Elevated ESR/CRP
Fever
Prolonged PR interval
51
Dyslipidemia
Patho: genetic issue; diet
S/Sx:
Symptoms of atherosclerosis
Yellow deposits around eyes
Dx: lipid panel
Tx: statins
Any form of ascvd, LDL 190+, DM 40-75 and LDL>70, 40-75 with 10yr risk >7.5%
Monitor for Rhabdo
Pearls:
Screening - age 35
High intensity = 50%+ lowering; moderate intensity = 30-50% lowering; low intensity = < 30% lowering
Add ezetimide next
52
Aortic stenosis
Patho: narrowing of aortic outflow - calcifications, rheumatic damage
S/Sx:
Fatigue, sob, doe, syncope/near syncope, CP
Systolic, right upper sternal border, radiates to carotids; decreases with valsalva and hand grip; louder with leaning forward and squatting and exhalation; S4 at apex; Split S2
Dx: Echo
Tx: Monitor, replace when severe or symptomatic; decrease afterload (ACEI)
Pearls:
Avoid lowering blood volume
53
Aortic regurgitation
Patho: can’t close - calcifications, damage, vegetation
S/Sx:
Sob, syncope, fatigue
Diastolic, blowing, left sternal border 3rd ics (Erb’s point); louder with sitting, leaning forward, exhaling, squatting, with hand grip; water hammer pulse; Austin Flint murmur (late diastolic rumble at apex)
Dx: Echo
Tx: reduce afterload, surgery
Pearls:
54
Mitral stenosis
Patho: rheumatic,
S/Sx:
Fatigue, sob; often asymptomatic
Diastolic, harsh, apex; louder with exhalation, squatting, left lateral decubitus; opening snap; split S1
Dx: Echo
Tx: reduce afterload, surgery
Pearls:
55
Mitral regurgitation
Patho: age, rheumatic, MI, MVP, infection
S/Sx:
Fatigue, doe, nocturia
Systolic, blowing, apex; louder with exhalation, squatting, hand grip; Split S2; radiates to axilla
Dx: Echo
Tx: reduce afterload; surgery
Pearls:
56
Pulmonary stenosis
Patho: congenital, infection
S/Sx:
Sob, abd fullness
Systolic, harsh, left upper sternal border; radiates to left shoulder; Split S2; louder with inspiration
Dx: Echo
Tx: diuretics; surgery
Pearls:
57
Pulmonary regurgitation
Patho: PHtn, damage, congenital — rare
S/Sx:
DOE
Diastolic, blowing, left upper sternal; louder with inspiration
Dx: Echo
Tx: surgery
Pearls:
Have to distinguish from aortic regurg – will be louder with inspiration
58
Tricuspid stenosis
Patho: congenital, rheumatic
S/Sx:
DOE; edema
Diastolic, harsh, left lower sternal border; louder with inspiration
Dx: Echo
Tx: surgery balloon valvuloplasty
Pearls:
59
Tricuspid regurgitation
Patho: infection, RV failure/dilation from PHtn or LV failure
S/Sx:
DOE
Systolic, blowing, left lower sternal border; louder with inspiration; JVD, edema
Dx: Echo
Tx: Surgery - balloon valvuloplasty
Pearls:
60
Acute bronchiolitis
Patho: RSV infection; inflammation of bronchioles
Risks: child < 2yrs
S/Sx:
Dyspnea, cough
Dx: CXR/CT shows peribronchial cuffing, perihilar infiltrates, atelectasis; antigen detection
Tx: supportive care; hospitalize if O2<95%, age < 3m, resp rate > 70, atelectasis
Pearls:
Ribavirin for severe lung/heart disease or immunocompromised
Palivizumab for prophylaxis
RSV vaccine
61
Acute bronchitis
Patho: multiple infections, mostly viral; inflammation of bronchi
S/Sx:
Persistent cough, some sputum, low grade fevers
Wheezing, rhonchi; no consolidation
Dx: clinical; neg cxr
Tx: bronchodilators; steroids; rest; OTC cough suppressant; fluids
Pearls:
ABX if immunocompromised, more than 10 days - 2nd gen ceph or macrolide
62
Croup
Patho: viral infection, allergies; inflammation of larynx
S/Sx:
Barking cough, hoarseness
Inspiratory stridor
Dx: clinical; neg lateral neck xray; steeple sign on AP neck
Tx: inhaled racemic epinephrine; supportive; steroids (dexa)
Pearls:
63
Pertussis
Patho: Bordatella pertussis
S/Sx:
Coughing fits with vomiting
Dx: culture/PCR; serology
Tx: Macrolide (“mycin”); bactrim if allergy
Pearls:
Vaccination: 5 doses DTaP - 2m, 4m, 6m, 15-18m, 4-6 yr; Tdap booster 11-18 yrs and each pregnancy
64
Acute respiratory distress syndrome
Patho: sepsis, trauma, injury (aspiration, toxic inhalation, drowning) – increased permeability of alveolar-capillary membrane
S/Sx:
Dyspnea, frothy sputum
Crackles, decreased breath sounds
Dx: CT, CXR; normal BNP; PaO2/FiO2 < 300
Tx: supportive - ventilation, fluids, abx
Pearls:
Bilateral infiltrates that spare the costophrenic angles
LOW Peep
65
Cystic fibrosis
Patho: disruption in chloride transport across membrane
S/Sx:
Recurrent infections; poor digestion - foul-smelling stools; FTT
Dx: sweat chloride test (will be high)
Tx: percussive tx; digestive enzymes
Pearls:
Complicated by Pseudomonas and MDRO
Often have bronchiectasis
66
Foreign body aspiration
Patho: obstruction of airway
Risks: kids, dysphagia, psych, sedatives
S/Sx:
Cough, wheezing, drooling
Wheezing; decreased/absent breath sounds; inspiratory stridor possible
Dx: CXR - expiratory view will show hyperinflation and mediastinal shift; Need ABG for evaluating ventilation
Tx: Bronch, surgery
Pearls:
RML/RLL is most common
67
Types of hypersensitivity reactions
Type 1 - mediated by IgE (allergies, anaphylaxis, asthma)
Type II - cytotoxic reaction mediated by IgG or IgM (autoimmune)
Type III - reaction mediated by immune complexes (RA, post-strep GN, reactive arthritis, lupus, hypersensitivity pneumonitis)
Type IV - delayed reaction mediated by cellular response (contact derm, celiac disease, MS, PPD)
68
Anaphylaxis
Patho: Type I hypersensitivity reaction
S/Sx:
Dyspnea, nausea/vomiting, abd pain, diarrhea, hives
Wheezing, decreased breath sounds, stridor; chest retractions; hypotension; angioedema
Dx: clinical
Tx: epinephrine; antihistamines; steroids; IV fluids
Pearls:
69
Asthma
Patho: allergic inflammation and bronchospasm
S/Sx:
Dyspnea, sob, wheezing
wheezing
Dx: PFTs - obstructive with >10% improvement with bronchodilator, peak flow rate
Mild intermittent - < 2 episodes/week, < 2 nocturnal/month, <2 rescue/wk; FEV1>80%
Mild persistent - 3-6 days/week, 3-4 noct/month, 3-6 rescue days but not more than 1 per day; FEV1>80%; minor limitations on activities
Moderate persistent - daily, 2-6 noct/week, daily rescue; FEV1 60-80%; some limitations
Severe persistent - continual sx, nightly, multiple daily rescue; FEV1 < 60%; very limited
Tx:
Mild intermittent - SABA as needed
Mild persistent - low dose ICS with SABA as needed or ICS/SABA daily
Moderate persistent - low dose ICS-formoterol and SABA as needed
Severe persistent -
med dose ICS-formoterol or ICS-LABA or ICS-LAMA;
med-high ICS-LABA+LAMA+SABA prn
High ICS-LABA, steroids, biologics
Pearls:
Exacerbation = O2, neb SABA, ipratropium, steroids
70
Chronic bronchitis
Patho: chronic inflammation of bronchial walls with thickening and mucus
Risk: smoking
S/Sx:
Cough, sob
Blue bloater; rhonchi
Dx: Productive cough for > 3months more than 2 years; CXR - hyperinflation; PFTs = obstructive w/o reversal, normal DLCO; ABG = chronic resp acidosis
Tx: smoking cessation; SABA/LABA, SAMA/LAMA, ICS
GOLD A - less sx, less exac = SABA or SAMA
GOLD B - more sx, less exac = LAMA or LABA
GOLD C - less sx, more exac = LAMA + SABA
GOLD D - more sx, more exac = LAMA; LABA+LAMA; ICS-LABA
Pearls:
Vaccinate flu, pneumococcal
O2 improves mortality
71
Emphysema
Patho: destruction of lung parenchyma
Risk = smoking, alpha 1 antitrypsin def
S/Sx:
Dyspnea
Pink puffer - thin, pursed lips; barrel chest, rhonchi
Dx: CXR/CT = bullae, hyperinflation; PFT = obstructive with no BD improvement and reduced DLCO
Tx: smoking cessation; O2; SABA/LABA, SAMA/LAMA, ICS; lung wedge resection
First = LAMA or LABA
Second = LABA + LAMA or LABA+ICS
Third = LABA + LAMA + ICS
Pearls:
72
Small cell lung cancer
Patho: 15%, smokers
S/Sx: cough, hemoptysis, wt loss
Dx: CXR, CT, biopsy, PET
Tx:
Pearls:
Does NOT respond to surgery – have to do chemo
Metastasizes quickly
ACTH and ADH releasing – Cushings and SIADH; Lambert-Eaton myasthenic syndrome
Central mediastinal mass
73
Non small cell lung cancer
Adenocarcinoma - most common; non-smokers; peripheral; Pancoast
Squamous cell carcinoma - second most common; central solitary mass; smokers; hemoptysis; possible Pancoast; PTHrP
Large cell carcinoma - rare, fast doubling rates
Carcinoid tumors: very rare; carcinoid syndrome - flushing, diarrhea, asthma from serotonin
Patho:
S/Sx:
Dx:
Tx: Stage ½ = surgery; stage 3 = chemo then surgery; stage 4 = palliative
Pearls:
74
Pulmonary nodules
Patho: < 3cm = nodule; >3cm = mass - >5.3cm likely cancer
DDx: lung abscess, hydatid cyst, wegeners granulomatosis
S/Sx:
Dx: CT, biopsy; surveillance if < 1cm, 3m/6m/yrly 2 yrs
Tx:
Pearls:
Ill-defined, lobular, spiculated – more likely cancer
75
pleural effusion
Patho:
Transudative – HF, cirrhosis, renal failure, nephrotic syndrome
Exudative - infection, malignancy, PE
S/Sx:
SOB, DOE
Low O2, crackles at bases; DECREASED tactile fremitus
Dx: CXR/CT, thoracentesis
Lights criteria - LDH fluid > .45x blood; protein fluid > .5x blood; LDH fluid > ⅔ ULN for blood
Tx: drain; treat underlying cause
Pearls:
76
Tension pneumothorax
Patho: penetrating wound to chest
S/Sx:
Trauma, SOB, pain
Tracheal deviation to contralateral side;
Dx: clinical; CT; US
Tx: immediate decompression - 2nd intercostal space, mid-clavicular line; chest tube
Pearls:
77
Spontaneous pneumothorax
Spontaneous
Patho: sudden collapse of pleural space - primary vs secondary
Risks: tall/thin; connective tissue disease; smoking; COPD/emphysema
S/Sx:
Pleuritic pain, acute, SOB
increased percussion, decreased breath sounds, decreased fremitus
Dx: CXR - expiratory/standing; US
Tx: >15% = chest tube (4th or 5th rib space at mid to anterior axillary line) and daily CXR
Pearls:
High flow O2 for 4-5 days causes nitrogen gradient which helps speed resorption of air
78
Pulmonary embolism
Patho: thrombus, usually DVT from leg
Risks: sepsis, pregnancy, immobility, hypercoag, oral contraceptives, cancer
S/Sx:
Pleuritic chest pain, sob, travel/immobility; maybe hemoptysis
Tachycardia, low O2, JVD, Homan’s if DVT
Dx: CTA or V/Q; d dimer for low suspicion; EKG = sinus tach / S1Q3T3
Tx: anticoag - at least 3 months; tPA/embolectomy; IVC filter
Pearls:
Can have fat embolus from long bone fx - also have petechial rash and confusion
Can have air embolus - scuba divers
Can have amniotic fluid embolus - can lead to DIC
CXR - westermark sign (clear area with reduced vascular markings) or Hampton hump (peripheral wedge shaped opacity with base along pleural surface)
79
Pulmonary hypertension
Patho: increased arterial pulm pressure (normal is 15/5)
Risks: lung disease; systemic HTN, LV failure, smoking, obesity; Mitral stenosis
5 types:
Idiopathic PAH
PAH due to left heart disease
PAH due to chronic lung disease
PAH due to chronic emboli
PAH from rare stuff
S/Sx:
Dyspnea, ?cough
Usually clear lungs
Dx: right heart cath; echo is supportive - RVSP >20; EKG – T wave inversion in V1-V4 and inferior;
Echo first, then CXR/EKG/CT chest/PFT with DLCO/sleep study; RHC if no cause found
Tx:
Endothelin receptor antagonists (“-entan”)
diuretics/digoxin/anticoagulants
PD4i
Pearls:
80
Sleep apnea and OHS
Patho: increased arterial pulm pressure (normal is 15/5)
Risks: lung disease; systemic HTN, LV failure, smoking, obesity; Mitral stenosis
5 types:
Idiopathic PAH
PAH due to left heart disease
PAH due to chronic lung disease
PAH due to chronic emboli
PAH from rare stuff
S/Sx:
Dyspnea, ?cough
Usually clear lungs
Dx: right heart cath; echo is supportive - RVSP >20; EKG – T wave inversion in V1-V4 and inferior;
Echo first, then CXR/EKG/CT chest/PFT with DLCO/sleep study; RHC if no cause found
Tx:
Endothelin receptor antagonists (“-entan”)
diuretics/digoxin/anticoagulants
PD4i
Pearls:
81
Bacterial pneumonia
Patho:
Strep pneumo; Staph aureus; Klebsiella; Mycoplasma; Mycobacterium
S/Sx:
Productive cough, fever, malaise, dyspnea
Increased fremitus, decreased breath sounds, +egophony
Dx: sputum culture; antigen detection; CXR - consolidation, air bronchograms; CT chest
TB - PPD or IGRA for latent; sputum stain/culture + NAAT for active
Tx: abx
Azithro or amox or doxy
Comorbidities = (azithro or doxy) + (augmentin or ceftin [cefuroxime]); fluoroq
Rocephin + (azithro or doxy)
Vanc + zosyn; fluoroq; cefepime; merrem
Pearls:
Rust colored sputum = Strep pneumo; more common after splenectomy
Red jelly sputum = Klebsiella; also alcoholics
Pink sputum = S. aureus; often after flu
Legionella = GI sx, low sodium, higher fever
Mycoplasma = +cold agglutinins, bullous myringitis, lower fever, dry cough
H. influenzae = COPD, smokers
Chlamydia pneumo = college; sore throat; long prodrome
TB = apical; cavitary
Empyema = complication
82
Fungal pneumonia
Patho:
Pneumocystis; dimorphic; Aspergillus
S/Sx:
Fever, cough, malaise - abx don’t work
Dx: sputum culture/stain; beta d glucan; antigen detection; PCR/NAAT; CXR/CT chest - bilateral
Tx:
Fluconazole, itraconazole; amphotericin B
Pearls:
Pneumocystis - CD4<200; CAN’T CULTURE; Bactrim + steroids
Histoplasmosis - bird/bat; hilar lymphadenopathy; amphoterrible
Aspergillus - COPD; voriconazole
Cryptococcus - soil; meningitis; amphoterrible
Coccidio - azole; hot dry areas
83
Viral pneumonia
Patho:
Influenza, RSV, parainfluenza
S/Sx:
Cough, fever, malaise, wheezing
Bilateral rhonchi, no consolidation
Dx: CXR/CT chest - bilateral; antigen detection; PCR/NAAT
Tx: supportive care;
Pearls:
Influenza = oseltamivir
RSV = ribavirin
84
Osteoporosis
Patho: bone demineralization; leads to fractures
Risks: steroids; low calcium; genetic
S/Sx: fractures - compression, long bone at early age
Dx: DEXA scan - t score < -2 for age matched group
Tx: calcium + vitamin D
Pearls:
85
Hyperthyroidism and thyrotoxicosis
Patho: Usually Graves disease - ab against TSH receptor; other would be cancer
S/Sx:
Wt loss, tremor, sweating, tachycardia, afib, diarrhea, anxiety, heat intolerance
Exophthalmos, tremor, enlarged thyroid; increased deep tendon reflexes; pretibial myxedema
Dx: low TSH, high T3/T4; anti-TSH receptor Ab; imaging
Tx: ablation, sugery; methimazole or phenylthiouracil (PTU ok in preg); BB
Pearls:
Toxicosis - fever, severe tachycardia, psychosis, coma, n/v/d, shock -
86
Hypothyroidism
Patho: autoimmune destruction - anti-thyroxine perioxidase, anti-thyroglobulin ab
S/Sx:
Wt gain, fatigue, cold intolerance, dry skin, bradycardia, hypothermia,
Decreased reflexes, dry skin, bradycardia; high cholesterol
Dx: elevated TSH, low T3/T4; +ab tests; imaging
Tx: synthroid
Pearls:
87
Thyroid cancer
Patho:
Types:
Anaplastic - worst
Medullary - familial (part of MEN2)
Follicular
Papillary - 80% (papillary is popular)
Risks: radiation, FH
S/Sx: mass, hoarseness, dysphagia
Dx: US/biopsy, CT, thyroid uptake
Tx: thyroidectomy
Pearls:
Females 40-60 = most common
88
Thyroiditis
Patho:
Types:
Reidel - fibrous
Subacute - inflammation/post-viral
Suppurative - infectious (Staph or Strep)
Drug induced – lithium, amiodarone, interferon alpha, tyrosine kinase inhibitors
S/Sx:
Dx: ESR/CRP, thyroid panel, WBC
Tx:
Pearls:
89
Primary Adrenal insufficiency
Patho: usually autoimmune destruction of adrenal glands; secondary from steroids or pituitary adenoma
S/Sx:
Weakness, fatigue, N/V/D
Hyperpigmentation, hypotension, thin; hyponatremia, hyperkalemia, elevated BUN, hypercalcemia, hypoglycemia
Dx: low am cortisol, high ACTH, cosyntropin stim test, CT
Tx: hydrocortisone, may need fludrocortisone
Pearls: needs increased dose if sick/surgery
WBC - neutropenia, lymphocytosis, eosinophilia
90
Cushing syndrome
Patho: often pituitary adenoma; other is adrenal tumor or ectopic tumor (small cell lung CA, pancreatic cancer, thymoma); exogenous steroids
S/Sx:
Wt gain, abd weight, striae, buffalo hump, moon facies, hypertension, irregular or absent period; HA, nausea, vision issues if pituitary adenoma
Elevated BP, striae, hyperglycemia, hump, facies; hypokalemia, hirsutism
Dx: elevated midnight cortisol, 24hr urine, dexa suppression test; high dose dexa will distinguish causes; ACTH; imaging
Tx: surgery; ketoconazole in inoperable pts
Pearls:
91
Diabetes insipidus
Patho: Inability to respond to ADH or lack of ADH
Meds: lithium
S/Sx: polyuria, polydipsia, nocturia
Dx: 24 hr urine volume > 3L; water deprivation + desmopressin challenge; hypernatremia
Tx: central - give ADH (desmopressin); nephrogenic - volume control
Pearls:
92
SIADH
Patho: too much ADH
Cancers: small cell lung cancer
Other - stress, pain, brain injury, TB, pneumonia
Meds: NSAIDS, sulfonylureas, SSRIs
S/Sx: weakness from hyponatremia;
Dx: hyponatremia, urine Na> 40; Urine Osm > 100
Tx: fluid restriction, Na tablets; ADH receptor antagonists (‘vaptans’)
Pearls:
93
Hyperparathyroidism
Patho: elevated PTH
Primary = adenoma
Secondary = CKD, vitamin D def
S/Sx:
abd pain; constipation; malaise; depression; arthralgias; n/v; polyuria with dehydration
Hypercalcemia; hypophosphatemia
Dx: elevated Ca with high PTH (low Ca with elevated PTH with kidney disease)
Tx: surgery; fluids; calcitonin; bisphosphonates; lasix
Pearls:
94
Hypoparathyroidism
Patho: low PTH;
Risks: radiation, thyroid / neck surgery, autoimmune
S/Sx:
Dry skin
Carpal spasms with BP (Trousseau sign); prolonged QT on EKG; perioral parasthesia; Chvostek sign
Dx: low calcium, low PTH; high phosphate
Tx: calcium
Pearls:
95
Hypertriglyceridemia
Patho: abnormal production of triglycerides; abnormal metabolism
S/Sx: maybe pancreatitis; atherosclerosis; subcutaneous xanthomas
Dx: lipid panel - trigs > 150
Tx: low fat diet; statins; fibrates
Pearls:
Screen at 20 and every 5 years
Severe = >886
96
Metabolic syndrome, obesity
Patho: excess calories
Overwt 25-30; obese 1 30-35; obese 2 35-40; obese 3 40+
Kids - BMI 95%+
Metabolic syndrome =
HDL < 40/50; HTN, hypertrig, impaired glucose, waist circum 35+/40+
Maybe metformin; lifestyle modifications
S/Sx:
Dx:
Tx: orlistat, liraglutide, bariatric surgery
Pearls:
97
Type 1 diabetes mellitus, diabetic ketoacidosis
Patho: autoimmune destruction of pancreatic beta cells
S/Sx:
n/v, abd pain, wt loss, polyuria, polydipsia, thirst, confusion
Kussmaul breathing, dry skin
Dx: fasting glucose, A1C, oral GTT; antibodies
Tx: insulin
Treat DKA with IV Fluids, insulin, maybe potassium; monitor anion gap, glucose, bicarb
Pearls:
98
Type 2 diabetes mellitus, hyperosmolar hyperglycemic syndrome
Patho: reduced sensitivity to insulin, reduced insulin production
Risks: chronic pancreatitis, obesity
S/Sx:
Polyuria, polydipsia, wt gain, acanthosis nigrans, confusion
Dry skin
Dx: fasting glucose, A1C, oral GTT;
Tx:
Biguanide
Metformin (Glucophage)
Decreases hepatic glucose
Lactic acid
AKI
Sulfonylureas
Glipizide (Glucotrol)
Glimeperide (Amaryl)
glyburide
Increases insulin secretion
hypoglycemia
SGLT2i
“Gliflozin”
Invokana (canagl)
Farxiga (dapagl)
Jardiance (empagl)
Inhibits renal resorption of glucose
UTI
Euglycemic DKA
Thiazolidinediones
“Glitazone”
pioglitazone(Actos)
Rosi (Avandia)
Increases insulin sensitivity
Bladder cancer
HF
fractures
DPP4i
“Gliptin”
Januvia (sitag)
Tradjenta (Linag)
Blocks DPP4 that inactivates GLP1
Pancreatitis
GLP1 analogues (Incretin mimetics)
“Glutide”
Trulicity (dulagl)
Victoza (liraglu)
Ozempic / Wegovy (semaglu)
Byetta (exenatide)
Slows gastric emptying; reduces appetite
pancreatitis
Alpha-glucosidase i
Acarbose
Slows digestion of carbs
Pearls:
99
Vitamin D deficiency
Patho: low intake vitamin D
S/Sx: fatigue, depression
Rickets, osteomalacia
Dx: 25OH vit D
Tx: supplements
Pearls:
100
Cholecystitis
Patho: inflammation of wall of gallbladder due to gallstones
Risks: gallstones; sludge; fat/female/fertile/forty
S/Sx:
RUQ pain, n/v,
Murphy+; RUQ pain;
Dx: ultrasound, CT, HIDA (gold std); elevated ALP, maybe bili
Tx: low fat diet, abx; surgery
Pearls:
Boas sign = radiation to right subscapular area
Chronic chole = porcelain GB (premalignant)
Acalculous cholecystitis = no stone
Stones most common = cholesterol
101
Cholangitis
Patho: infection of biliary tree; sometimes from obstruction
S/Sx:
Fever, RUQ pain, jaundice + confusion, hypotension (Charcot triad / Reynolds pentad)
Dx: CBC, lactic, blood cultures, US; ERCP
Tx: broad spectrum abx covering anaerobes; ERCP; lab chole
Pearls:
102
Primary sclerosing cholangitis
Patho: inflammation and fibrosis of intra- and extra-hepatic bile ducts
Autoimmune; males 30-50
S/Sx:
Progressive jaundice; pruritis
Dx: HIDA, MRCP, labs, (ERCP is negative); pANCA; smooth muscle Ab+
Tx: UDCA
Pearls: associated with ulcerative colitis; and with cholangiocarcinoma; proceeds to cirrhosis and risk for HCC
103
Primary biliary cholangitis
Patho: inflammation and fibrosis of intra-hepatic bile ducts only; ?cause - likely immune
S/Sx:
Progressive jaundice; pruritis
Dx: HIDA, MRCP, labs, (ERCP is negative); anti-mitochondrial antibodies+
Tx: UDCA; liver transplant
Pearls: associated with ulcerative colitis
104
Cholelithiasis
Patho: gallstones without inflammation
Types:
Cholesterol (85%) - fibrates, OCPs, hemolysis, elevated trig;
Pigmented (10%)
S/Sx: colicky RUQ pain after eating; n/v
Dx: ultrasound
Tx: low fat diet; ursodiol ursodeoxycholic acid); surgery if symptomatic
Pearls:
105
Acute hepatitis
Patho: viral, drugs, autoimmune, alcohol inflammation of liver
S/Sx:
Jaundice, icterus, n/v, RUQ pain, fever
Hepatomegaly; jaundice; RUQ pain
Dx: LFTs - ALT>AST; US; CT
Tx: supportive; drug = detox
Pearls:
Hep A - travel to asia; contagious until 1 week of jaundice; IgM; vaccination 12 months
Hep B - sex/blood; flu-like sx + jaundice; surface Ag vs anti-surface Ab
Hep C - sex/blood; chronic; testing - antiHCV, then PCR; tx - sofosbuvir, grazoprevir, daclatasvir; screen 18-79 yrs once
Hep D - only w/ Hep B; PEG-IFN x 1 yr
Hep E - high in utero mortality; IgM anti-HEV
EtOH - AST/ALT 2+; Maddrey discriminant factor > 32 = steroids
106
Chronic hepatitis
Patho: viral, alcoholic
S/Sx:
Jaundice, itching, nausea, abd distention
Hepatomegaly, jaundice
Dx: LFTs - AST>ALT, US, CT, Hepatitis B, C, D testing
Tx:
Hep B - alpha-interferon 2b, lamivudine, adefovir
Hep C -
sofosbuvir + “-atasvir” 12 weeks or glecaprevir + pibrentasvir 8 weeks if no cirrhosis
Sofosbuvir + velpatasvir 12 weeks or glecaprevir + pibrentasvir 12 weeks OR sofosbuvir + daclatasvir 24 weeks if compensated cirrhosis
Sofosbuvir + velpatasvir 24 wks or sofosbuvir + daclatasvir 12 weeks or liver transplant if decompensated cirrhosis
Hep D - PEG-IFN x 1 yr
Hep E - if + 6 months, ribavirin
Pearls:
Hep B - sex/blood; flu-like sx + jaundice; surface Ag vs anti-surface Ab; vaccine 0,1,6 months
Hep C - sex/blood; chronic; testing - antiHCV, then PCR; tx - sofosbuvir, grazoprevir, daclatasvir; screen 18-79 yrs once
Hep D - only w/ Hep B; PEG-IFN x 1 yr
107
Cirrhosis
Patho: fibrosis of liver
Risks: alcohol use, viral hepatitis, autoimmune, alpha 1 anti-trypsin def, drugs, NAFLD/NASH, Wilson’s disease (copper)
S/Sx:
Ascites, jaundice, bruising/bleeding, abd distention, blood in stool, confusion
Fluid wave, distention, spider veins on abd, jaundice, edema, petechiae, asterixis; palmar erythema, caput medusae
Dx: gold stnd = biopsy; CT/US; AST>ALT, hypoalbumin, thrombocytopenia, long PT/INR; EGD for esophageal varices
Tx: supportive; BB for varices; diuretics; low salt diet; lactulose for NH4; paracentesis; abx for SBP; cholestyramine for itching
Pearls:
Monitor for hepatocellular carcinoma - AFP and us q 6 m
Budd Chiari (hepatic vein thrombosis) - abd pain, ascites, hepatomegaly
108
Acute liver failure
Patho: drugs (Tylenol); hepatitis; Budd-Chiari syndrome (blockage of hepatic veins); Wilson dx; sepsis; HELLP syndrome
S/Sx: jaundice; encephalopathy, n/v, fluid overload, RUQ pain
Dx: INR>1.5; elevated ammonia, hypoglycemia; elevated LFTs
Tx: multifactorial; need fluids
Pearls:
109
Nonalcoholic fatty liver disease
Patho: fat deposition in liver (>10% hepatocytes with fat droplets on bx); can lead to inflammation (NASH)
Risks: obesity; DM
S/Sx: often asymptomatic
Mild hepatomegaly
Dx: imaging - US; LFTs; bx is gold standard
Tx: low fat diet
Pearls
110
Acute pancreatitis
Patho: inflammation of pancreas
Risks: gallstones; alcohol; triglycerides; trauma; ACEi; cystic fibrosis; scorpion sting; hypercalcemia; ERCP
S/Sx:
n/v, abd pain
Epigastric tenderness
Dx: lipase/amylase; CT, ERCP, MRCP; lipid panel, elastase
Tx: fluids, anti-emetics, NG tube or bowel rest, pain meds
Pearls:
Risk of cysts, diabetes, pancreatic insufficiency
Cullen sign = umbilical bruising
Grey-Turner’s sign = flank ecchymosis
Ranson criteria - mortality / prognosis - labs at admission and 48 hrs
111
Chronic pancreatitis
Patho: recurrent pancreatitis
S/Sx: same
Dx: same
Tx: same
Pearls:
Classic triad = diabetes, steatorrhea, pancreatic calcifications
112
Pancreatic cancer
Patho: adenocarcinoma
Risks: DM, chronic panc; smoking; obesity
S/Sx: painless jaundice; diarrhea; wt loss; enlarged GB
Dx: CT, US, bx, CA19-9
Tx: surgery (Whipple, chemo
Pearls:
Usually at head
Courvoisier’s sign = palpable GB
Virchow’s node = palpable LN in left supraclavicular fossa
113
Dysphagia
Patho: many causes
Strictures - Schatzki rings, masses, GERD
Impaired muscle movement - achalasia, nutcracker esophagus, Systemic sclerosis, diffuse esophageal spasms, Zenker diverticulum, neurogenic
S/Sx: impaired swallowing of solids and/or liquids
Dx: Upper GI series, MBS (barium esophagram), manometry, endoscopy
Tx: depends on disease - dilation, treat underlying condition, surgery, neitrates or CCB for spasms; botulinum toxin for achalasia
Pearls:
Auerbach plexus - nerve cells in esophagus lost in achalasia
114
Esophageal varices
Patho: varicose veins of esophagus, likely due to cirrhosis or other causes of portal hypertension or blockage
Risks: alcohol, smoking
S/Sx: GI bleed (hematemesis or melena); ? dysphasia, ? early satiety
Dx: EGD
Tx: banding or sclerotherapy, clipping if bleeding; BB to reduce BP; NG tube; IV ocreotide; IV cipro or IV rocephin ppx for 1 week
Pearls:
Screen every 2-3 years (without) or 1-2 years (with small)
Blakemore tube - balloon tamponade used for 48 hrs
Can do TIPS (transjugular intrahepatic portosystemic shunt)
70% of rebleeds occur within 1 yr
115
Esophagitis
Patho: inflammation / infection of esophagus
Pathogens / Causes:
Non-infectious: Gerd, pill; Medications (NSAIDS, bisphos); eosinophilia; radiation; corrosive
Infectious: candida, HSV, CMV, MAC, Tb
S/Sx: pain, difficulty swallowing
Dx: endoscopy with culture/biopsy
Tx: depends on cause
Eosinophilia - remove allergen, treat with steroids
HSV = acyclovir
CMV = ganciclovir
Corrosive = steroids
Candida = fluconazole 100
Pearls:
Eosinophila = ribbed esophagus (corrugated rings)
HSV = multiple shallow ulcers
116
Peptic ulcer disease
Patho: H pylori infection most common; can be from reduction of prostaglandins which thins the mucus layer (NSAIDS) or from overproduction of gastrin (Zollinger)
Risks: NSAIDs, smoking, antacids?, overweight; spicy or acidic food; infants
Types: duodenal (pain improves with food); gastric (pain worse with foods)
S/Sx: pain after eating, nausea/vomiting; dyspepsia; chronic cough
Dx: biopsy; CLO test for H pylori; can do stool antigen; gold standard = pH probe study
Tx:
H2 blockers - famotidine, nizatidine, cimetidine
PPI: omeprazole, lansoprazole, esomeprazole, pantoprazole, dexlansoprazole, rabeprazole
H pylori:
3 drug = clarithromycin, amoxicillin (or metronidazole), PPI
4 drug = bismuth, metronidazole, tetracycline, PPI )if ANY prior macrolide tx (preferred)
Lifestyle changes - upright after eating, earlier meals, raise head of bed, wt. loss
Pearls:
Risk of Barrett esophagus and adenocarcinoma
PPIs - risk of low B12, low Mg, low Ca (hip fx), C diff, increased risk of PNA
117
Pyloric stenosis
Patho: stricture at the pylorus (hypertrophy and hyperplasia); before 3 months of age
S/Sx: projectile vomiting after eating; mass in upper abd (olive shaped in epigastrium)
Dx: Barium upper GI - “string sign”; Labs - hypochloremia, hypokalemia; US = “double track”
Tx: surgery (pyloromyotomy)
Pearls:
118
Gastritis
Patho: inflammation of the stomach
Risks: NSAIDS, H pylori, stress, Zollinger-Ellison syndrome, foods, medications, alcohol, HSV or CMV
S/Sx: dyspepsia, n/v, abd pain, early satiety
Dx: clinical; endoscopy; urea breath test
Tx: trial of H2 blocker, trial of PPI, endoscopy / H pylori testing and tx
Pearls:
119
Gastroesophageal reflux disease
Patho: loosening of lower esophageal sphincter allowing regurg of stomach contents into esophagus
Risks: anticholinergics, antihistamines, tricyclics, CCB, nitrates, progesterone
S/Sx: dyspepsia, epigastric abd pain, chronic cough
Dx: clinical, pH manometry; endoscopy if doesn’t improve with tx
Tx: H2, PPI; lifestyle changes; trial med for 8 weeks
Pearls:
Risk of Barrett esophagus and esophageal adenocarcinoma - red flags = vomiting, wt loss, anemia, melena
120
Celiac disease
Patho: Autoimmune ab against transglutimase, T cell mediated damage; gliadin
S/Sx: abd pain, n/v, dermatitis herpetiformis, diarrhea, wt loss, IDA, aphthous ulcers
Dx: duodenal bx; anti-transglutaminase Ab
Tx: gluten-free diet; steroids (if refractory)
Pearls:
121
Small-bowel obstruction
Patho: blockage of SB
Causes: mass, stricture (IBD), intussusseption, volvulus, adhesion; outside mass; ileus
S/Sx: abd pain, n/v, obstipation
High pitched bowel sounds
Dx: xray, CT
Tx: NG tube, treat cause, surgery
Pearls:
122
Intussusception
Patho: telescoping of a proximal section of intestine into an adjacent distal section
Risks: kids; viral infection
90% is ileocecal
S/Sx: “currant jelly stools” (bloody mucusy), crampy colicky intermittent abd pain; vomiting
Abd distention, ttp, sausage-shaped mass in RUQ
Dx: CT, US, barium or air enema
Tx: resuscitation first - IV abx, fluids, and NG tube; enema, surgery
Pearls:
Adults - usually from a mass
Xray = crescent or meniscus sign; bull’s eye/target sign
US = target sign
123
Anal abscess/fistula
Patho: abscess, usually in posterior area; fistula = track to outside of skin beside anus
S/Sx: pain, fever, drainage
Dx: clinical, CT/US; anoscopy
Tx: abx - need to treat anaerobes, drainage; sitz bath; high fiber diet and stool softener
Pearls:
Fistula associated with Crohn disease
Fournier gangrene = necrotizing fasciitis in that area
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Colon cancer
Patho: adenocarcinoma
Risks: smoking, genetic, diet, etoh, IBD
S/Sx: change in bowel habits; abd distention, bowel obstruction, melena, wt loss
Mass on palpation, anemia
LLQ = obstruction; RLQ = anemia
Dx: colonoscopy with biopsy; imaging (CT, barium x-ray); CEA
Tx: surgery, chemo (5 fluorouracil)
Pearls:
Screening - 45-75 yrs (10 yrs prior to relative’s age of dx); 10yr colonoscopy, yearly hemoccult or cologuard; 5 yr flex sig; CT colonography 5 yrs.
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Hemorrhoids (internal, external)
Patho: swollen and inflamed veins
External - distal to the dentate line
Internal - proximal to the dentate line
S/Sx:
External - Pain with defecation; can be thrombosed - purplish swelling
Internal - bleeding on toilet paper; feeling of incomplete evacuation
Dx: visualization; DRE;
Tx: banding; sitz baths; fiber; stool softener; witch hazel; sclerotherapy; excision if thrombosed
Pearls:
Internal classification -
Grade 1 = do not prolapse below dentate line
Grade 2 = prolapse with pressure, reduce spontaneously
Grade 3 = prolapse with pressure, manual reduction
Grade 4 = irreducible
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Anal fissure
Patho: linear erosion, usually posterior; often from passing hard or large stool, maybe Crohn’s disease
S/Sx: severe pain with defecation; possible bleeding
Dx: visualization; sentinel pile (external skin tag)
Tx: stool softener; fiber; surgery if needed (lateral anal sphincterectomy); topical vasodilator (nifedipine or NTG); lidocaine gel
Pearls:
127
Appendicitis
Patho: inflammation and infection of the appendix; most commonly from fecolith
S/Sx:
RUQ pain, fever, n/v
Rovsing; McBurney; Psoas; Obdurator
Dx: CT, US
Tx: surgery; abx (3rd gen cephalosporin)
Pearls:
128
Irritable bowel syndrome
Patho: hypersensitivity of intestines
S/Sx:
Abd pain, better with defecation; gas; constipation, diarrhea; post-prandial urgency
No clinical findings
Dx: clinical, rule out bad stuff
Tx: fiber; less fat; drug tx for dominant sx
Lubiprostone for constipation
Pearls:
Rome criteria: presence of abdominal pain/discomfort at least 3 days/month for 3 months with 2+ of — improvement with defecation; onset associated with change in freq of defecation; change in consistency of stool; no red flag sx
Subtypes:
IBS with predominant constipation
IBS with diarrhea
Mixed IBS
Unclassified IBS
Red flag sx: rectal bleeding, wt loss, fever
? associated with Giardia lamblia
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Inflammatory bowel disease
Patho:
Crohn - anywhere in digestive tract except rectum; skip lesions; transmural
UC - progressive from anus in large intestine - most common is terminal ileum; mucosa/submucosa
S/Sx:
Diarrhea (UC more likely to be bloody), n/v, abd cramping; aphthous ulcers (Crohns)
Dx: colonoscopy with biopsy
Crohn = skip lesions; cobblestoning; transmural; non-caseating granulomas; ASCA+ (anti-saccharomyces cerevisiae antibodies)
UC = erythematous and friable; mucosa only; crypt abscesses; p-ANCA+; “lead pipe” on barium enema
Tx:
Drugs:
Sulfasalazine (5ASA) - blocks prostaglandin release
Metronidazole
Steroids - prednisone, budesonide
Immunosuppressants - azathioprine, 6-mercaptopurine
Bile acid sequestrants - cholestyramine, colestipol
Surgery
Pearls:
Can cause nutritional deficiencies - vit D, Vit B12
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Ischemic bowel disease
Patho: blockage of mesenteric arteries
Risks: afib, atherosclerosis, DM, HTN, AAA
S/Sx: abd pain out of proportion, abd pain after eating, minimal physical exam findings; bloody diarrhea
Dx: CTA; LDH high; hemoccult+; thumbprint sign - edema on radiograph or CT
Tx: anti-coagulation; surgery for stent/bypass
Pearls:
Most common = superior mesenteric artery
Ischemic colitis - most common; decreased blood flow in watershed areas (splenic flexure, rectosigmoid junction)
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Large-bowel obstruction
Patho: obstruction due to mass, volvulus, intussusception, adhesion, etc
S/Sx: obstipation, pain, distention, late signs = vomiting
High pitched bowel sounds
Dx: imaging - CT, x-ray
Tx: NG tube, bowel rest, IV fluids, possible surgery
Pearls:
132
Infectious diarrhea
Patho: Multiple pathogens
Giardia, worms
E coli, Vibrio cholera, Campylobacter jejuni, Salmonella, Shigella, Yersinia, Clostridioides, Staph aureus, Cryptococcus
Rotavirus, norovirus
S/Sx: loose stools, may be bloody
Dx: stool culture, stool ova/parasites, stool lactoferrin
Tx: possibly abx, IV fluids, anti-diarreal meds (loperamide, diphenoxylate, paregoric, codeine)
Pearls:
133
Noninfectious diarrhea
Patho: possibly functional - spasms; medications; ischemia
S/Sx: diarrhea
Dx: rule out infectious
Tx: depends on cause
Pearls:
134
Constipation
Patho: slow motility of stool thru intestine
Causes: medications; reduced peristalsis, obstruction, hypothyroidism, DM, MS, dehydration
S/Sx: hard painful stools,
Dx: stool motility studies
Tx: bulking agents; prokinetics (laxatives), increase hydration, exercise,
Pearls:
Rome criteria: any two — straining, hard stools, incomplete evacuation, digital disimpaction, anorectal obstruction sensation with 25%+ of BM; <3 BM/week = for 3 months with sx onset > 6 months
Encopresis = recurrent soiling of clothes
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Diverticulitis and diverticulosis
Patho: outpouching of the haustra; infection - ‘itis’; ‘osis’ can cause painless rectal bleeding
Risks: constipation, low fiber diet
S/Sx:
Llq abd pain, fever, nausea, distention
TTP in LLQ
Dx: CT (xray to r/o perforation); NOT colonoscopy
Tx: liquid diet; abx (cipro/flagyl or unasyn); surgery; blood transfusion; high fiber diet
Pearls:
Predictors: absence of vomiting; CRP > 5; TTP LLQ
136
Toxic megacolon
Patho: dilation of the colon
Risks: C diff; constipation; ileus; UC/Crohn; meckel diverticulum? Hirschsprung?
S/Sx:
Abd distention; obstipation; pain; fever
Fever; tachycardia;
Dx: xray - dilation > 6 cm; CT
Tx: surgery; decompression
Pearls:
Dx = radiographic evidence + (3- fever/tachycardia/leukocytosis/anemia) + (1- dehydration, confusion, electrolyte imbalance; hypotension)
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Fecal incontinence
Patho: anal sphincter weakness (trauma, DM, cord injury, sclerosis) - pudendal nerve; decreased rectal sensation; decreased rectal compliance; fecal impaction with overflow
Risks: age, diarrhea, DM, hormone therapy after menopause
Types:
Urge incontinence
Passive incontinence
S/Sx:
Dx: stool studies; endoscopy; anorectal manometry; defecography
Tx: bulking agents; anti-diarrheals; biofeedback; anal sphincteroplasty; colostomy
Pearls:
138
Lactose intolerance
Patho: reduction of lactase enzyme
S/Sx: postprandial bloating, flatus, diarrhea, abd pain - 30 min to 2 hrs
Dx: lactose breath test; fecal pH test (acidic stool = bad)
Tx: avoidance; lactase
Pearls:
139
Foreign body ingestion
Patho: mostly in kids; complications = perforation or obstruction
S/Sx: irritability, abd pain, n/v, fever, melena
Dx: xray
Tx: endoscopy, surgery,
Pearls:
Once past the esophagus, most will pass
Batteries have to be removed at once
140
Toxic ingestion (caustic substances, medications)
Patho:
S/Sx:
Dx:
Tx:
Pearls:
Hydrocarbons - avoid emetics and lavage; oxygen
Bases - EGD; avoid vomiting; small amts water
Tylenol - tylenol levels; LFTs; gastric lavage in 1st hour; charcoal within 2 hrs; N-acetylcysteine
Aspirin - fever, confusion, hyperpnea; metabolic acidosis and hypokalemia; charcoal, IV fluids, dialysis
Organophosphates - sweating, twitching, miosis; red cell cholinesterase level; tropine + pralidoxime
Iron - GI bleed; met acidosis; gastric lavage; desferoxamine
Mercury - diarrhea, hyperhidrosis; chelating
Lead - neuropathy; screen at 12 and 24 months; chelating
Arsenic - HA, abd pain, diarrhea, garlic breath; urine test; chelating
CO - HA, cherry red skin, lactic acidosis; CO; hyperbaric O2
Cyanide - coma, almond breath; HAGMA, high venous O2; Thiosulfate, nitrites
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Gastrointestinal bleeding
Patho: depends on etiology
S/Sx: melena, hematochezia, hematemesis, coffee-ground emesis
Dx: EGD, tagged RBC scan, colonoscopy; CT
Tx: depends on etiology
Pearls:
142
Hiatal (diaphragmatic)
Patho: protrusion of stomach into chest
S/Sx: GERD, vomiting, hematemsis
Dx: barium upper GI, CT
Tx: PPI; surgery; wt loss
Pearls:
143
Ventral hernia (at site of prior surgery)
Patho: weakened area from surgery
S/Sx: palpable mass
Dx: clinical; CT
Tx: surgery
Pearls:
144
Umbilical hernia
Patho: weakened area around umbilicus
S/Sx: mass around umbilicus
Dx: clinical; CT
Tx: surgery if persists after 2 yrs or incarcerated
Pearls:
145
Indirect inguinal hernia
Patho: passage thru internal inguinal ring, may pass into scrotum
S/Sx:
Dx: US
Tx:
Pearls: most common
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Direct inguinal hernia
Patho: passage thru the external inguinal ring at Hesselbach’s triangle; doesn’t enter scrotum – medial to the inferior epigastric vessels
S/Sx:
Dx: US
Tx:
Pearls:
147
Acute osteomyelitis
Patho: infection of bone, often hematogenous spread
S/Sx: bone pain, fever, drainage if fistula, swelling, redness
Dx: xray (demineralization, periosteal reaction, bone destruction), MRI, biopsy/culture; ESR/CRP
Tx: IV abx based on source - 6 weeks; remove hardware
Pearls:
Staph aureus = most common
Pott disease = TB osteo
Sickle cell patients = Salmonella
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Avascular necrosis
Patho: destruction of blood supply to bone, usually hip;
Risks: steroids, sickle cell anemia, trauma, lupus, hypercoag, radiation, leukemia
S/Sx: pain, reduced movement P/AROM
Dx: xray, CT, MRI
Tx: surgery/replacement
Pearls:
Legg-Calves-Perthes = AVN in kids
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Bursitis
Patho: Inflammation of bursae
Risks: trauma, overuse
S/Sx: pain with compression; pain with activity; ROM preserved with no increase in pain
Dx: clinical; aspiration for crystals or infection
Tx: NSAIDs; ice; steroids
Pearls:
150
Carpal tunnel syndrome
Patho: inflammation of median nerve due to overuse
Anatomy: reticulum of wrist
Risks: repetitive movement of wrists
S/Sx: numbness/tingling of 1-3 fingers (worse at night)
Tinel and Phalen; atrophy of thenar eminence
Dx: clinical; nerve conduction studies;
Tx: NSAIDs, wrist braces, steroid injections, surgery
Pearls:
151
Compartment syndrome
Patho: muscle necrosis due to reduced blood flow due to swelling
Risks: fracture, surgery, burns, tight dressings/casts
S/Sx: pain, pallor, paresthesia, pulseless, cold
Dx: elevated CPK; fasciotomy with opening pressure; pressure measurements (>30 mmHg); doppler?
Tx: fasciotomy
Pearls:
152
Fibromyalgia
Patho: inflammation of connective tissue
Risks: hypothyroid, RA, sleep apnea
S/Sx: fatigue, brain fog, pain, depression, sleep isssues, HA, abd pain
Pain with trigger point palpation
Dx: clinical - at least 3 months, no other dx, pain index score > 7
Tx: exercise, antidepressants, cognitive therapy, wt loss
Pearls:
153
Fractures and dislocations - Salter Harris
Salter Harris:
Type 1 - pulled apart
Type 2 - thru and above plate
Type 3 - thru and below plate
Type 4 - above and below
Type 5 - crush
154
Fractures and dislocations - ribs
Flail chest - 2 fractures in 3+ consecutive ribs; increased resp rate, discordant motion
155
Fractures / dislocations - legs
Hip:
Subcapital, intertroch, subtroch - surgery / replacement; risk of AVN; shortened and externally rotated
Knee:
Risk for popliteal artery injury
Tib plateau - compression injury; swollen with ecchymosis; cast or surgery
Patella fx = direct injury; can’t straighten knee; x-ray; 6-8 wk immobile or surgery
Patella dislocation / sublux - usually lateral; RICE, PT
Ankle/Foot:
Jones fx - 5th MT; Pseudo-Jones involves the joint itself; poor blood supply; 6 wks NWB
Stress fx - most common in 2nd/3rd MT, calcaneus, tib, femur, humerus; x-ray often negative, MRI may show; 6-12 wks rest
Talus fx - high energy cause; risk of AVN
Tibial plafond fx -high energy compression fx of distal tibia; ORIF
Weber ankle fx classification
A - fibula fracture below level of syndesmosis
B - fibula fx at level of mortise
C - fibula fx above level of mortise – unstable from ligament and syndesmosis tear
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